Linearity Sample Order Form – WSLH Proficiency Testing

Enrollment Information

This request is for enrollment year:(Required)

Identification Information

WSLH PT ID (7 digits)

Current/previous account ID (if known)

CLIA ID

If application in progress, enter "Pending"

Contact Information

Please enter the contact information of the person completing this form

Facility Name(Required)

Name(Required)

First Last

Phone(Required)

Example: (123) 456-7980

Email(Required)

Billing Information

Facility Name

Contact Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Example: (123) 456-7890

Fax

Email(Required)

Shipping Information

Fill in ONLY if new customer or information is different than PT enrollment.

Check here if the same as billing information

Check here if same as billing information

Facility Name(Required)

Contact Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Example (123) 456-7890

Fax

Email(Required)

Order Information

It will be necessary to refer to the Linearity Products price list while completing this portion.

Blood Gas

Check to view Blood Gas

Please check box to view Blood Gas products

Cardiac

Check to view Cardiac

Please check box to view Cardiac products

Chemistry

Check to view Chemistry

Please check box to view Chemistry products

Diabetes

Check to view Diabetes

Check the box to view Diabetes products

Drug Monitoring & Abuse

Check to view Drug

Please check the box to view Drug Monitoring & Abuse products

Immunoassay

Check to view Immunoassay

Please check the box to view Immunoassay products

Immunology

Check for Immunology

Please check the box for Immunology products

Order Total

Shipping

Order Total

Payment Information

VISA/MC: If you wish to pay by credit card, please wait for your invoice for instructions.

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